Provider Demographics
NPI:1205167772
Name:KOUTROULAKIS, ALEXIS ANNA-MAY (LCSW)
Entity type:Individual
Prefix:MISS
First Name:ALEXIS
Middle Name:ANNA-MAY
Last Name:KOUTROULAKIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 N 2ND ST
Mailing Address - Street 2:1L
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-1300
Mailing Address - Country:US
Mailing Address - Phone:717-475-3105
Mailing Address - Fax:
Practice Address - Street 1:247 N 2ND ST
Practice Address - Street 2:1L
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-1300
Practice Address - Country:US
Practice Address - Phone:717-475-3105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-24
Last Update Date:2010-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0163321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical